Pressure Injuries Caused by Medical Devices and Other Objects: a Clinical Update

Home , Pressure ulcer

WOUND WISE 1.5 HOURS CE Continuing Education A series on wound care in collaboration with the World Council of Enterostomal Therapists Pressure Injuries Caused by Medical Devices and Other Objects: A Clinical Update

A review of practical resources, including mnemonics, to aid in prevention and identification.

ABSTRACT: At the April 2016 National Pressure Ulcer Advisory Panel (NPUAP) consensus conference, terminology and staging definitions were updated and two definitions were revised to describe pressure injuries (PIs) caused by medical devices or other items on the skin or mucosa. Here, the authors discuss the etiology and prevention of PIs resulting from medical and other devices, the frequency of such injuries, and the bodily sites at which they most often occur. They provide an overview of the current NPUAP guideline, highlight important risk factors, and explain why mucosal PIs cannot be staged.

Keywords: medical device–related pressure injuries, mucosal pressure injuries, National Pressure Ulcer Ad- visory Panel, pressure injury, pressure injury staging, pressure ulcer, SORE mnemonic, DEVICE mnemonic

ressure injuries (PIs), formerly known as bed- pressure ulcer was replaced by pressure injury to sores, decubiti, pressure sores, or pressure ul- underscore the fact that PIs may be present even Pcers, have been a nursing concern since the when the skin is intact, and the definitions of medi- time of Florence Nightingale. In April 2016, the Na- cal device–related PIs (MDRPIs) and mucosal mem- tional Pressure Ulcer Advisory Panel (NPUAP) shone brane PIs were revised.1 (See Figure 1 for a depiction a spotlight on this issue by convening a consensus of intact, undamaged skin.) The NPUAP currently conference in which associated terminology and defines MDRPIs as PIs that “result from the use of staging definitions were updated. (The 2016 staging devices designed and applied for diagnostic or ther definitions can be found on the NPUAP website: apeutic purposes,” noting that on the skin such PIs www.npuap.org/resources/educational-and-clinical- tend to take on “the pattern or shape of the de- resources/npuap-pressure-injury-stages.) The term vice” (see Figure 2) and “should be staged using

36 AJN ▼ December 2017 ▼ Vol. 117, No. 12 ajnonline.com By Barbara Ann Delmore, PhD, RN, CWCN, MAPWCA, IIWCC-NYU, and Elizabeth A. Ayello, PhD, RN, ACNS-BC, CWON, FAAN

the [NPUAP] staging system.”1 The NPUAP defines mucosal membrane PIs as those “found on mucous membranes with a history of a medical device in use Hair shaft at the location of the injury,” noting that mucosal Duct of PIs cannot be staged because histologic characteris- sweat gland tics of mucosal tissue do not allow clinicians to dis- tinguish partial from full-thickness tissue loss.1, 2 In championing the prevention of PIs caused by Epidermis Horny layer Cellular layer medical and other devices, the NPUAP has raised Sebaceous awareness of the injury such devices can inflict on gland the skin or mucosal membranes and has clarified Muscle that erects hair shaft Dermis that the classification system used to stage PIs of Sweat gland the skin cannot be used to describe PIs of the mu- Hair follicle cosal membranes (see Skin and Mucosal Pressure Injuries3-9). The Joint Commission and the National Vein Nerve Database of Nursing Quality Indicators have ad- Subcutaneous Artery opted the new terminology, and discussions between tissue the NPUAP and the Centers for Medicare and Med- icaid Services (CMS) about incorporating the revised Figure 1. Layers of intact, undamaged skin. © 2013 Lippincott Wil- language are under way.10, 11 At press time, the CMS had recognized that a variety of terms are used in liams and Wilkins. All rights reserved. both long-term care facilities and long-term care hospitals to describe and document PIs. The CMS has further acknowledged that “it is acceptable to The general scope of PI frequency is reflected in code pressure-related skin conditions in Section M the International Pressure Ulcer Prevalence (IPUP) [on skin conditions in the Minimum Data Set] if dif- Survey, which has been collecting data annually from ferent terminology is recorded in the clinical record, participating facilities since 1989, when it was intro- as long as the primary cause of the skin alteration is duced by the medical technologies provider Hill-Rom. related to pressure.” 9, 12 Nevertheless, setting-specific Its large database pulls information from a wide vari- standards can be seen in some CMS terminology ety of care settings, including acute, long-term, long- and in staging and coding instructions (see Pres- term acute, rehabilitative, and home care. The most sure Injuries and CMS Documentation Regula- recent IPUP survey report provided data on 918,621 tions9, 12-15). patients treated in U.S. facilities over a 10-year period Although the change in terminology from pres- and showed a decline in the prevalence of acute care sure ulcer to pressure injury has been controversial, facility–acquired PIs from 6.4% to 2.9% between in this article we focus instead on the etiology and 2006 and 2015; but the report did not specify the prevention of PIs resulting from medical devices proportion of PIs related to medical or other devices.17 and other objects. We also discuss the frequency of device-related PIs and the bodily sites at which they most often occur. We also review the evidence pre- sented in current guidelines and identify the risk fac- Nurses should consider all tors that may increase a patient’s vulnerability to device-related PIs. patients with a medical device to ETIOLOGY AND FREQUENCY OF DEVICE-RELATED PIs be at risk for medical device– All PIs are believed to result from pressure or a com- bination of pressure and shear forces, though other factors, such as microclimate, nutrition, perfusion, related pressure injuries. comorbidities, and the condition of soft tissue, may influence a patient’s ability to tolerate pressure.1, 16 As our understanding of PI etiology has evolved, aware- For various reasons, there is relatively little infor- ness and concern about PIs caused by medical and mation available on the risks or frequency of device- other devices has increased in clinical practice. Sur- related PIs. First, some clinicians do not acknowledge prisingly, however, research on the frequency of such them as PIs, either because they’re unaware of the injuries is limited. NPUAP terminology or they disagree with the NPUAP [email protected] AJN ▼ December 2017 ▼ Vol. 117, No. 12 37 captured in prevalence or incidence data. Addition- ally, though the Glamorgan Scale acknowledges medical devices as potential PI risks, the Braden Scale, commonly used to assess PI risks in adults, does not take such devices into consideration.18, 19 The extent to which medical devices cause PIs may, however, be gleaned from several studies that have specifically reported on these data. For example, in 2009, VanGilder and colleagues sampled 86,932 U.S. acute care patients and found that 1,631 of the 17,911 PIs (9.1%) were device related, with 785 of these facility acquired.20 Device-related PIs were most commonly found on the ear (20%), sacral– coccyx region (17%), heel (12%), and buttocks (10%). Black and colleagues reported on a subset of data (collected during eight quarterly PI incidence and prevalence studies conducted at the Nebraska Medical Figure 2. A pressure injury resulting from the hub Center) that included 2,079 adult patients who were PI free on admission to a critical care, step-down, or of an iv line that was secured directly to the skin. medical–surgical unit.21 Of the 2,079 patients, 113 Notice the imprint on the skin that matches the de- (5.4%) developed hospital-acquired PIs, 39 (34.5%) of sign of the hub. Photo © 2015 BA Delmore. which were related to medical device use. When prob- ability was calculated, patients who were using a medical device were found to be 2.4 times more likely to and believe that device-related PIs or at least muco- develop a PI of any kind than patients who were not. sal device-related PIs should be categorized differ- An analysis by Apold and Rydrych of hospital- ently. Consequently, these types of PIs are not always ized patient data collected through Minnesota’s

Table 1. Key to the NPUAP, EPUAP, and PPPIA Strengths of Evidence and Strengths of Recommendation

Strengths of Evidence A The recommendation is supported by direct scientific evidence from properly designed and imple- mented controlled trials on pressure ulcers in humans (or humans at risk for pressure ulcers), providing statistical results that consistently support the recommendation. (Level 1 studies required.) B The recommendation is supported by direct scientific evidence from properly designed and imple- mented clinical series on pressure ulcers in humans (or humans at risk for pressure ulcers) providing statistical results that consistently support the recommendation. (Level 2, 3, 4, 5 studies.) C The recommendation is supported by indirect evidence (e.g., studies in healthy humans, humans with other types of chronic wounds, animal models) and/or expert opinion. Strengths of Recommendation Strong positive recommendation: definitely do it Weak positive recommendation: probably do it No specific recommendation Weak negative recommendation: probably don’t do it

Strong negative recommendation: definitely don’t do it

EPUAP = European Pressure Ulcer Advisory Panel; NPUAP = National Pressure Ulcer Advisory Panel; PPPIA = Pan Pacific Pressure Injury Alliance. Note: Level refers to the “level of evidence” assigned to a study based on study design and quality. Reprinted with permission from the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Austra- lia; 2014.

38 AJN ▼ December 2017 ▼ Vol. 117, No. 12 ajnonline.com Skin and Mucosal Pressure Injuries3-9 Understanding the essential differences.

Epithelial tissue functions to protect, secrete, and absorb.3 The stratified squamous epithelia occur in two forms: keratinized (meaning it contains the protein keratin, which makes tissue waterproof) and nonkeratinized (meaning it contains no keratin and thus must be kept moist).3 The epidermis, the skin’s outermost layer, consists of the keratinized form, whereas the mucous membranes contain the nonkeratinized form. Keratinocytes are found both in the keratinized epidermis4 and, in varying degrees, in the oral epithelium.5, 6 In healthy epidermal tissue, keratinocytes are not activated; rather, they become activated when the tissue is injured, allowing the epidermis to heal through reepithelialization.4, 7 Once the epider- Figure 3. Skin vs. mucous membrane. Used with permis- mal tissue is healed, the keratinocytes return to a deactivated sion of the National Pressure Ulcer Advisory Panel, 2017. state. It has long been known that oral keratinocytes differ from epidermal keratinocytes. Depending on their location within pressure from medical devices” and cautioning that pressure the mouth (in the palate or in the tongue, for example), kera- applied to mucosal tissue by such devices as urinary cathe- tinocytes also differ in form, structure, and differentiation. ters, or oxygen, endotracheal, orogastric, and nasogastric With the exception of the oral mucosa, which has a unique tubing, “can render it ischemic and lead to ulceration.”8 How- response to injury,5, 6 mucous membranes do not keratinize8 ever, since mucosal tissue differs histologically from skin tissue and thus do not undergo reepithelialization. Keratinization is (see Figure 3), and the NPUAP PI staging system is based on the process by which protein within epithelial tissue is hard- skin and its underlying anatomical structures, mucosal PIs can- ened and made insoluble. Since the mucosal tissue, which not be staged. Furthermore, clinical assessment of mucosal tis- lines body cavities, is constantly kept wet, it does not kera- sue does not allow partial tissue loss to be distinguished from tinize. full-thickness tissue loss. For these reasons, mucosal PIs are not The National Pressure Ulcer Advisory Panel (NPUAP) ad- coded in Section M on skin conditions in the Centers for Medi- dressed the problem of mucosal pressure injuries (PIs) in care and Medicaid Services’ Resident Assessment Instrument 2008, noting that mucosal tissue is “especially vulnerable to of the Minimum Data Set (see Figure 4).9

Where Is the Medical Device–Related Pressure Injury?

Skin Mucosa

• Stage using the NPUAP staging • Cannot stage using the NPUAP staging classiﬁcation system classiﬁcation system • Count as a pressure injury • Count separately as a pressure injury • Track incidence separately for • The CMS does not code in pressure trends ulcer section M on MDS • Track incidence separately for trends

Figure 4. Staging and classification differences between skin and mucosal pressure injuries. © 2016 EA Ayello and BA Delmore. CMS = Centers for Medicare and Medicaid Services; MDS = Minimum Data Set; NPUAP = National Pressure Ulcer Advisory Panel.

[email protected] AJN ▼ December 2017 ▼ Vol. 117, No. 12 39 mandatory statewide reporting system showed that hours worn or percentage adherence between the for 63% of reported device-related PIs, there was no two groups.23 documentation of device removal at regular intervals for cleaning, pressure relief, or skin inspection, and 74% of such PIs were not discovered until they were stage 3 or more.22 The authors suggest that contrib- Mucosal medical device–related uting factors may have included unfamiliarity with best practices for skin inspection and failure to re- pressure injuries must be place ill-fitting devices, such as temporary cervical collars applied on admission to stabilize the spine, counted and tracked separately with better-fitting devices. The free movement of ill- fitting devices can exert shear forces on the tissue, which—depending on where the device is located— from skin pressure injuries. clinicians may be unable to relieve. In a study of 200 ICU patients in a Missouri hospital who were receiving noninvasive ventilation either The frequency of MDRPIs may be even higher by nasal–oral mask or full-face mask, Schallom and in pediatric populations. When Visscher and Taylor colleagues found that patients considered full-face conducted a two-year prospective study of 741 neo- masks significantly more comfortable than nasal– natal ICU patients at the Cincinnati Children’s Hos- oral masks and that full-face masks were associated pital Medical Center, they found that nearly 80% of with significantly fewer PIs (2% versus 20%); there all PIs and 90% of PIs in premature infants were as- were no significant differences, however, in mean sociated with medical devices.24

Pressure Injuries and CMS Documentation Regulations9, 12-15 For reimbursement purposes, the staging and classification of PIs must closely follow setting-specific standards. The Centers for Medicare and Medicaid Services (CMS) issues documentation regulations that may vary depending on the type of facility—long-term care (LTC) facility, long-term care hospital (LTCH), rehabilitation center, or acute care hospital. Although patients continue to be at risk for device-related pressure injuries (PIs) when they transition from an acute care hospital to an LTC facility, an LTCH, or a rehabilitation facility, the CMS rules and regulations that govern these care settings differ, requiring nurses and other clinicians to closely follow the setting-specific documentation standards regarding staging and classification of PIs. LTC facilities must complete the Resident Assessment Instrument (RAI) of the Minimum Data Set (MDS) upon patient admission and discharge, as well as quarterly. In their documentation, nurses and other health care providers working within these facilities must follow the directions for completing Section M on skin conditions, using the CMS definitions as set forth in the RAI of the MDS, which differ somewhat from those used by the National Pressure Ulcer Advisory Panel (NPUAP). Although nurses and other health care providers in the acute care setting do not code the MDS, their documentation is used by hospital coders for reimbursement purposes. For this reason, they need to document the type or etiology of all injuries; the stage of the injury if a PI, and whether it was present on admission or occurred during hospitalization. Health care providers must bear in mind that there are differences in setting-specific standards, evident in CMS terminology, as well as in staging and coding instructions. While the CMS acknowledges that both the terms pressure ulcer and pressure injury may be used in the medical record documentation for LTC facilities and LTCHs, documents available on the CMS website indicate that, as of 2018, the word injury will ap- pear only on the revised MDS 3.0 Section M form for inpatient rehabilitation facilities and LTCHs.13, 14 In LTC facilities and LTCHs, the RAI manuals instruct clinicians not to code oral mucosal pressure ulcers in Section M (on skin conditions).9, 12 However, only LTC facilities are instructed to capture those ulcers in item L0200C (on abnormal mouth tissue).9 Similarly, the CMS Updated Inpatient Rehabilitation Facility Patient As- sessment Instrument (IRF-PAI) Training Manual instructs clinicians not to code mucosal ulcers on the IRF-PAI.15 All three CMS documents emphasize that mucosal pressure injuries cannot be staged using the NPUAP skin pressure ulcer staging system because mucosa and skin differ anatomically. At press time, the CMS had issued no reimbursement guidance for acute care hospitals other than the 2008 requirement to document any stage 3-or-higher pressure ulcers that are present on admission.

40 AJN ▼ December 2017 ▼ Vol. 117, No. 12 ajnonline.com Figure 5. DEVICE Mnemonic for the Prevention and Treatment of Medical Device–Related Pressure Injuries etermine that all medical devices D • are commercially manufactured for use in the clinical setting (not homemade). • can be placed without making contact with prior or existing pressure injuries.

valuate all devices, every skin–device interface, and the surrounding skin at least twice daily, and E more often in patients with localized or generalized edema. erify that all nursing staff have been taught how to correctly use and secure medical devices and V understand that mucosal medical device–related pressure injuries must be counted and tracked separately from skin pressure injuries.

dentify all medical devices on all patients, especially those most vulnerable to medical device– I related pressure injuries: critically ill patients, neonates, children, older adults, and bariatric patients.

onsider the following any time medical devices are in use: C • Does the patient still require use of the device—can it be rotated, repositioned, replaced, or removed? • Is the fit correct? • Can a prophylactic dressing be used beneath devices placed in high-risk areas (the nasal bridge, for example)? E ducate all staff to look for objects that might be in the bed or chair under the patient. © EA Ayello and BA Delmore. This mnemonic was created from recommendations in the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014.

A worldwide challenge. Despite the recent atten- occurrence of MDRPIs.25 For each recommendation, tion device-related PIs have received in the form of the guideline provides both strengths of evidence guidelines and consensus statements by the NPUAP, (using grades A, B, or C) and strengths of recom- European Pressure Ulcer Advisory Panel (EPUAP), mendation (using “thumbs up,” “thumbs down,” and Pan Pacific Pressure Injury Alliance (PPPIA),1, 25 or “thumb neutral” illustrations) (see Table 1). The they remain a problem worldwide. In a study of ICU strength of evidence grade is based on the level of patients in Saudi Arabia, 115 of the 431 patients supporting evidence (study design and quality); the (26.7%) had at least one MDRPI (11 had two, and strength of recommendation rating was assigned by one had three).26 Of the 395 total PIs, 128 (32.4%) consensus vote and signifies the degree of confidence were MDRPIs. Endotracheal tubes and indwelling clinicians have that adhering to the recommendation urinary catheters were each responsible for 47 (37%) “will improve patient outcomes.”25 of the MDRPIs. Other common sources included Among the MDRPI recommendations, a few over- neck collars (n = 16; 12.5%), nasogastric tubes (n = arching themes emerge, including the following25: 12; 9.4%), traction equipment (n = 2; 1.6%), and • Consider all patients with a medical device to be at all other devices (n = 4; 3%). risk for MDRPIs (strength of evidence, B; strength of recommendation, “two thumbs up”). CLINICAL GUIDELINE RECOMMENDATIONS • Inspect the skin surrounding and under any The Prevention and Treatment of Pressure Ulcers: medical device at least twice a day for signs of Clinical Practice Guideline,25 which was developed pressure-related injury (strength of evidence, C; through a formal consensus process by the NPUAP, strength of recommendation, “one thumb up”). EPUAP, and PPPIA, is considered the national stan- • Inspect the skin more than twice a day if the pa- dard for the prevention and treatment of PIs related tient is at risk for fluid shifts or shows signs of to the use of medical devices. The guideline includes localized or generalized edema (strength of evi- 19 recommendations focused specifically on MDRPIs, dence, C; strength of recommendation, “two which cover how to assess patient risk, select and fit thumbs up”). medical devices, assess the skin and the medical de- • Remove potential device-related sources of pres- vices’ effect on the skin, and ultimately prevent the sure as soon as medically possible (strength of [email protected] AJN ▼ December 2017 ▼ Vol. 117, No. 12 41 Figure 6. At left is the cervical collar that caused the pressure injuries at right, on the patient’s neck and jawline. Photos © 2015 EA Ayello.

evidence, C; strength of recommendation, “two Regardless of how they’re labeled, however, they can thumbs up”). cause PIs (see Figure 7). • Reposition the patient or device to redistribute Another potential risk is when objects such as cor- pressure and reduce shear forces (strength of ev rective glasses or toys are left, not on a bedside table, idence, C; strength of recommendation, “two but within the patient’s bed or chair—along with thumbs up”). items some patients hoard, such as plastic eating We’ve created a mnemonic to help clinicians re- utensils, food items, and personal products. Com- member many of these recommendations for prevent- monplace electrical equipment, such as phones, music ing and reporting MDRPIs (see Figure 5). To order a players, or electric razors, can find their way beneath copy of the complete clinical practice guideline or to a patient in a bed or chair. Call bells and electrical download a free copy of the quick reference guide, cords should be considered PI threats as well. We’ve visit the NPUAP website: www.npuap.org/resources/ created the SORE mnemonic to remind clinicians of educational-and-clinical-resources/prevention-and- other less obvious devices that put patients at risk for treatment-of-pressure-ulcers-clinical-practice-guideline. PIs (see Figure 8). A revision of this guideline is currently under way and is expected to be available in 2019.

EXPANDING THE CONCEPT OF DEVICE-RELATED PIs Clinicians and health care staff are familiar with medical devices that can cause PIs, such as pulse oximeters (which commonly cause PIs in young children), bilevel positive airway pressure (BiPAP) masks that fit over the bridge of the nose, electro- cardiogram leads, sequential compression devices, endotracheal tubes, urinary catheters, nasogastric tubes, nasal cannulas, and cervical collars (see Fig- ure 6). In addition to these medical devices, however, a variety of other items, including bedpans, needle caps, and diapers, can cause PIs. Depending on the practice setting, some items may be considered “stock items,” “objects,” “required medical devices,” or “electrical equipment.” For example, while thromboembolism-deterrent stockings may be considered a stock item in some facilities, in others Figure 7. A pressure injury from a thromboembolism- they may be considered a required medical device. deterrent stocking. Photo © 2016 BA Delmore.

42 AJN ▼ December 2017 ▼ Vol. 117, No. 12 ajnonline.com VULNERABLE POPULATIONS process and the critical and chronic illnesses associ- Although all patients are susceptible to device-related ated with advanced age make older adults more vul- PIs, some populations are more vulnerable than oth- nerable to PIs, including device-related PIs. When ers. These include neonates, infants, young children, older adults are admitted to a health care facility, older adults, and bariatric patients. they are often immobile, undernourished, or have Neonates, infants, and young children are vul- fluid and electrolyte disorders. Additionally, older nerable because of issues such as skin prematurity or adults may be unable to communicate pain because early development. They may be developmentally un- of cognitive decline or severe illness. able to communicate pain from a device (see Figure Bariatric patients are susceptible to PIs because 9). Younger children are known to have occipital PIs they are likely to have perfusion problems, increased because they have a larger head size in proportion sweating, increased risk of skin infection due to skin to the rest of the body, and studies reveal that med- folds, immobility, and shear forces owing to weight ical devices are the leading cause of PIs in this stress.27-29 Along with neonates and young children, group,18, 19 especially in critical care areas, where bariatric patients may be more susceptible to MDRPIs medical devices are in greater use. In a 2014 study because equipment, such as stretchers, mattresses, of 204 pediatric patients, Schlüer and colleagues bed frames, chairs, compression devices, heel boots, found that 38.5% of all PIs were caused by exter- and tracheostomy ties, are not properly sized for nal devices.19 Some clinicians are incredulous that them.18, 27, 30 Another concern for bariatric patients is neonates and other pediatric patients develop PIs, that devices, such as caps or tubing, may be obscured but as with any at-risk population, this population by skin folds. In our clinical experience, we’ve also should be treated with care that includes consistent observed that some bariatric patients feel there is a skin and risk assessment. stigma associated with using specially fitted equipment Older adults can be vulnerable to device-related and thus are reluctant to use it. PIs that result from skin changes such as cellular at- Patients undergoing surgery or receiving ICU care trition, compromised performance of normal cellular should be considered vulnerable to MDRPIs.31-35 Dur- functions, loss of dermal thickness, reduced cutaneous ing surgery, patients may be immobile for a prolonged blood flow, loss of subcutaneous fat, decreased sen- period (often four hours or more) and receive anes- sation, and decreased epidermal turnover. The aging thetic agents that alter response to pressure and pain.31

Figure 8. The SORE Mnemonic: Developed to Raise Awareness of Potential Sources of Pressure Injuries

Potential sources of device-related pressure injuries a, b

Stock items Objects Required medical devices Electrical equipment

• Bedpan • Toys • BiPAP masks • Phones • Diapers • Cutlery • IV hubs • Music players • TEDs • Food items • ETTs • Tablets • Incontinent pads • Toiletries • Tubing • Chargers • Needle caps • Toothbrush • Drains • Electrical cords • Comb • BIS monitors • Call bell • Hairbrush • BP cuffs • Razors • Eyeglasses • Hearing aids • Bottle caps

BiPAP = bilevel positive airway pressure; BIS = bispectral index; BP = blood pressure; ETTs = endotracheal tubes; TEDs = thromboembolism-deterrent stockings. a Classification as a medical device or equipment may vary with the practice setting. b This list is not all-inclusive. © 2017 Delmore, Ayello, Smart. [email protected] AJN ▼ December 2017 ▼ Vol. 117, No. 12 43 Figure 9. At left is the iv tubing the infant lay on that caused the pressure injury on his face and head, at right. Photos © 2015 EA Ayello.

PIs that occur during surgery may not be detected for prevention program that includes a sustainable 72 hours or more after surgery.36, 37 Common sources plan.26, 36, 38, 41, 42 All clinicians and staff should know include positioners, bispectral index monitors, table the plan for their facility or area and understand straps, and fasteners. that each member is an integral part of the team. During an ICU stay, a patient may be at elevated Successful patient outcomes can only happen when risk for MDRPIs because of anemia, low albumin lev- team members value and understand their role in els, hypotension, vasopressor therapy, and mechanical preventing device-related PIs. ▼ ventilation,32-35, 38-40 as well as recognized PI risks such as edema and immobility. Devices typically used in For 41 additional continuing nursing educa- ICUs, including BiPAP masks and endotracheal tubes, tion activities on pressure injuries, go to www. may contribute to the development of MDRPIs.38 Se- nursingcenter.com/ce. quential boots and fecal management systems have also been implicated in PI formation. Barbara Ann Delmore is a senior nurse scientist in the Center MDRPI risk may be elevated further in surgical for Innovations in the Advancement of Care, NYU Langone and ICU patients with a history of any of the fol- Health, New York, NY, and a member of the National Pressure lowing26, 38: Ulcer Advisory Panel (NPUAP) board of directors. Elizabeth A. Ayello is a faculty member at the Excelsior College School of • cancer Nursing, Albany, NY, clinical editor of Advances in Skin and • cardiovascular disease Wound Care, and a former NPUAP president and member of • peripheral vascular disease the board of directors. Contact author: Barbara Ann Delmore, [email protected]. The authors and planners have • pulmonary disease disclosed no potential conflicts of interest, financial or otherwise. • neurologic disease • diabetes mellitus REFERENCES 1. National Pressure Ulcer Advisory Panel. National Pressure Ulcer Advisory Panel (NPUAP) announces a change in ter- RAISING AWARENESS minology from pressure ulcer to pressure injury and updates Through its 2016 terminology changes, the NPUAP the stages of pressure injury [news release]. 2016. http://www. npuap.org/national-pressure-ulcer-advisory-panel-npuap- has tried to clarify some of the questions about the announces-a-change-in-terminology-from-pressure-ulcer-to- differences between MDRPIs that develop on the skin pressure-injury-and-updates-the-stages-of-pressure-injury. and those that develop on the mucosa. Raising aware- 2. National Pressure Ulcer Advisory Panel. NPUAP pressure in- ness that medical devices can cause PIs is an important jury stages. 2016. http://www.npuap.org/resources/educational- and-clinical-resources/npuap-pressure-injury-stages. step in addressing the incidence of MDRPIs and other 3. Paulsen DF. Epithelial tissue. In: Paulsen DF, editor. Histology device-related PIs. Awareness of all potential PI sources and cell biology: examination and board review. New York: and of specific patient populations that may be at McGraw-Hill; 2010. p. 59-72. elevated risk for PIs should increase vigilance by health 4. Morasso MI, Tomic-Canic M. Epidermal stem cells: the cra- dle of epidermal determination, differentiation and wound care staff. healing. Biol Cell 2005;97(3):173-83. Successful PI prevention requires two critical ele- 5. Adams D. Keratinization of the oral epithelium. Ann R Coll ments: an interprofessional team and a comprehensive Surg Engl 1976;58(5):351-8.

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